States of flux

A model of how primary care trusts might develop can be seen in US health maintenance organisations and in existing projects in the UK, explain Maureen Devlin and Judith Smith

Primary care trusts, which go live in April 2000, have been heralded as a UK hybrid of the US health maintenance organisations.1

The bringing together of purchaser and provider in a single organisation, the creation of a body with financial and clinical responsibility for the health of a defined population, and the fundamental principle of the primary care gatekeeper seem to echo many features of the US model (see box, below right).

But what do we know about the likely shape of PCTs? What will they do, who will be in them and how will they be organised? These questions and others were addressed at a Birmingham University policy seminar last summer, attended by clinicians and managers from the NHS and the private sector.

Existing models of primary care organisations in the UK and the US were used to explore the functions and opportunities likely to be offered by PCT status. It was clear that innovative primary care organisations were already in existence in parts of the NHS and that they offered important pointers for the creation and operation of PCTs. The case studies below and in the box, above right, show this.

South-west London total purchasing project

The south-west London total purchasing project has focused on clinically managed care as its primary objective for change.

The social care principles of case management and multidisciplinary assessment have been applied to patients with complex conditions. The resulting care pathways and service specifications have led to the development of new intermediate care services and the moving of£600,000 from hospital to community service provision.

The project is developing new patterns of integrated care where hospital and primary care sectors meet. Its ability to commission care and move resources to support this has been crucial to its achievements. It acknowledges the importance of primary care peer review and changing prescribing and referral patterns.

Warrington Primary Care Act pilots

The Warrington project is developing inter-agency integrated care with an emphasis on community development. In one of the two first-wave pilots, professional roles are being developed to reflect the needs of the local population.

The project team has worked closely with education and community services departments of the borough council to develop shared services. These relationships were helped by the fact that Warrington is a unitary local authority.

The success of the two first-wave pilots has led to bids to become second- wave pilot sites. These proposals include plans to integrate a primary school and a health centre in a single building.

The pilots provide a model which can be drawn on to develop PCTs. In a unitary authority, they can be particularly useful in developing inter- agency working, paving the way for successful integrated care in PCTs.

Medicentre primary healthcare centres

A perhaps surprising case study used for exploring the likely functions of PCTs was the Medicentre private primary healthcare centres.

Medicentres operate according to protocols for which they aim to gain accreditation.

All staff, including GPs, are salaried employees and their aim is to provide primary healthcare in settings and at times that are convenient to their target patients (young and middle-aged working people).

There is an intention to move towards an insurance or membership plan for primary care provision, and to integrate this with access to privately insured secondary care services.

Lessons

What do these apparently disparate examples of primary care provision tell us about the likely future shape of PCTs? We identified several key building blocks (see box above right).

The PCT is likely to be an integrated primary and community healthcare provider, developing pathways of care at the interface of what has traditionally been thought of as primary and secondary care. Intermediate care projects such as that developed by the south-west London total purchasing project are likely to become commonplace.

But the integration of services will not be confined to primary and community healthcare. Intermediate care provision in PCTs will lead to calls for closer working between health and social care agencies, and in particular the pooling of their resources at locality or PCT level.

There will also be demand to develop a sense of health and social care staff working for a single virtual or actual organisation. The Warrington case study points to the likelihood of new health and social care organisations emerging from PCTs.

Services provided by PCTs will focus on the principle of accessibility. This may entail more extensive opening hours or care provision in workplaces and shops - both features of the Medicentre model. Or it may involve co- location with schools or other community facilities.

Traditional roles and working patterns will be reshaped by PCTs. Integrated nursing teams will lead whole areas of service development and provision.

GPs may choose to be salaried, as in Medicentres and some Primary Care Act pilots. And managers will increasingly find themselves managing care pathways and programmes rather than departments or institutions.

PCTs will operate within the clinical governance framework. They will therefore need to have clear mechanisms for peer review of medical, nursing, paramedical and management practice, along with explicit ways of implementing changes to practice and supporting colleagues in need of development.

The feature of PCTs which most frequently leads to the comparison with HMOs is that of the single organisation acting as both commissioner and provider of services.

Commentators have pointed to the possibility of PCTs becoming 'local health agencies', with local people being enrolled with the trust for the provision of all care services, whether directly by the trust or indirectly through its contracts with other providers.2

What, then, does an exploration of the direct experience of existing primary care organisations tell us about the move towards PCTs in the NHS? Birmingham University health services management centre's HMOs and PCTs seminar came up with eight pointers for managers and clinicians who are engaged in developing PCTs (see box, left).

PCTs will have new roles, but some of their functions are already being performed in the NHS and the private sector.

Reflection on the precursors of PCTs offers some timely lessons. As the NHS becomes the New NHS, imagine what could be achieved if PCTs manage to combine the best of what has gone before with the new freedoms prefigured in the Primary Care Act and other pilot projects.

REFERENCES

1 Pollock A. The American way. HSJ 1998; 108 (5599) 28-29.

2 Ham C. Public, Private or Community: what next for the NHS? London: Demos, 1996.

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